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Accelerating the Elimination of Pediatric HIV and AIDS in Zimbabwe: End-of-Project Report 1

/ END-OF-PROJECT REPORT /NOVEMBER 2015 | PVO10/2009

THE ELIZABETH GLASER PEDIATRIC AIDS FOUNDATION— CHILDREN’S INVESTMENT FUND FOUNDATION PARTNERSHIP

ACCELERATINGTHE ELIMINATION OF PEDIATRIC HIV AND AIDS

—IN ZIMBABWE—

2 The Elizabeth Glaser Pediatric Aids Foundation—Children’s Investment Fund Foundation Partnership

/ TABLE OF CONTENTS /


Acronyms 4

Executive Summary

6

HIV and AIDS in Zimbabwe

10

EGPAF-Zimbabwe 14

Program Goals and Objectives under CIFF

18

Achieving Increased National Coverage

of PMTCT

20

Accelerating Pediatric ART

30

Developing Optimal M&E Systems

34

Health Systems Strengthening

38

Final Outcomes and Evidence of

Performance Improvement

42

Sharing Lessons Learned

44

Challenges and Future Directions

46

References 48

Appendixes 50

/ ACRONYMS /



ACCLAIMAdvancing Community-Level Action for Improving MCH/PMTCT KPI key performance indicator

AIDS acquired immune deficiency syndrome M&E monitoring and evaluation

ANC antenatal care MNCH maternal, newborn, and child health

ART antiretroviral therapy MOHCC Ministry of Health and Child Care

ARV antiretroviral MTCT mother-to-child transmission of HIV

AZT zidovudine NVP nevirapine

CDCU.S. Centers for Disease Control and Prevention OI opportunistic infection

CIFF Children’s Investment Fund Foundation OPHIDOrganization for Public Health Interventions and Development

DFATDCanadian Department of Foreign Affairs, Trade and Development OR operations research

DFID UK Department for International Development PCR polymerase chain reaction

DFP district focal person PEPFARU.S. President’s Emergency Plan for AIDS Relief

DHE district health executive PMI program management indicator

DHMT district health management team PMTCTprevention of mother-to-child transmission of HIV

DNO district nursing officer POC point-of-care

EDB electronic database QI quality improvement

EGPAF Elizabeth Glaser Pediatric AIDS Foundation SOP standard operating procedure

EID early infant diagnosis TAT turnaround time

EMTCT elimination of mother-to-child transmission TB tuberculosis

HIV human immunodeficiency virus UNAIDSJoint United Nations Programme on HIV and AIDS

IAS International AIDS Society VHW village health worker

IATT

United Nations Inter-Agency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and Children

WHO World Health Organization

ICASAInternational Conference on AIDS and Sexually Transmitted Infections in Africa ZAPP-UZ

Zimbabwe AIDS Prevention Project-University of Zimbabwe

IEC information, education, and communication

6 The Elizabeth Glaser Pediatric AIDS Foundation—Children’s Investment Fund Foundation Partnership

/ EXECUTIVE SUMMARY /



In 2009, Zimbabwe had one of the highest burdens of new HIV infections in the world and was experiencing a mother-to-child HIV transmission (MTCT) rate of 30%.1 Two global health partners, the Elizabeth Glaser Pediatric

AIDS Foundation (EGPAF) and the Children’s Investment Fund Foundation (CIFF), collaborated to turn the tide on this epidemic by focusing on improving maternal, newborn, and child health (MNCH) in Zimbabwe while working hand-in-hand with a host-country government eager to address a widespread HIV epidemic and strengthen child survival.

In December 2010, shortly after the World Health Organization (WHO) released new prevention of mother-to-child HIV transmission (PMTCT) guidelines, recommending a longer duration of more effective antiretroviral (ARV) regimens among HIV-positive pregnant and breastfeeding women (Option A and Option B), CIFF awarded EGPAF a five-year, US$45 million grant to support Zimbabwe’s Ministry of Health and Child Care (MOHCC) in dramatically accelerating the elimination of pediatric HIV and AIDS in Zimbabwe. CIFF’s investment came just as momentum was building in the global health community to ensure universal coverage of PMTCT services and ultimately create a generation free of HIV. In 2011, the Joint United Nations Programme on HIV and AIDS (UNAIDS) released a call to end pediatric HIV and AIDS through its Global Plan toward the elimination of new HIV infections among children by 2015 and keeping their mothers alive, wherein 22 high-burden countries were prioritized for the scale-up of effective PMTCT programming (Zimbabwe was one of these 22 countries).2

EGPAF’s aim in Zimbabwe under CIFF’s initiative was to optimize the effectiveness of PMTCT programs to maximize HIV-free survival among children at 24 months of age. The specific goal was to reduce the risk of MTCT from an estimated 30% to less than 12%, using WHO 2010 PMTCT guidelines implementation as a catalyst. The approach centered on improving testing, treatment, and tracking of both mother and child and on increasing access to PMTCT care, as recommended by the then new WHO 2010 guidelines (Option A).*3

EGPAF’s work throughout the project, from 2010 through 2015, focused on

• expansion of comprehensive PMTCT services;

• optimization of comprehensive PMTCT services;

• strengthened capacity and commitment around the PMTCT program at the national, district, and community levels; and

• promotion of lessons learned throughout the project to inform the global response to the epidemic.

*Option A was one option of recommendations under the WHO 2010 PMTCT guidelines. The regimen includes twice daily antiretroviral prophylaxis for the mother and infant from early gestation through one week post-breastfeeding cessation.


Specifically EGPAF worked on rapid expansion of services from 38 districts to all 62 districts, scaling up capacity of Zimbabwe’s health system through a district-based approach and ensuring sustainability and local ownership of the national PMTCT program. EGPAF worked with district health leaders and communities to ensure greater national demand for and access to quality PMTCT services among HIV-positive pregnant and breastfeeding women, as well as appropriate education on safe infant feeding practices. EGPAF also worked with districts to improve mother-baby retention in the PMTCT cascade and access to immediate and effective care and treatment among HIV-exposed and HIV-infected infants and children.

EGPAF worked with all levels of Zimbabwe’s national health system to prioritize improvements in monitoring and evaluation (M&E) systems, ensuring better tracking of PMTCT and HIV care and treatment program outcomes. The improvements in M&E allowed the MOHCC to make accurate and informed decisions about the national PMTCT and HIV care and treatment programs. The focus on high-quality program data and the increased attention on the sharing of lessons learned enabled a great level of documentation and programmatic best practice sharing with many stakeholders and organizations within Zimbabwe and beyond—a key deliverable under CIFF’s award.

Close collaboration with in-country partners formed an essential component of both CIFF’s and EGPAF’s program implementation models. These relationships with local partners, including the JF Kapnek Charitable Trust, the Organization for Public Health Interventions and Development (OPHID), and Zimbabwe AIDS Prevention Project–University of Zimbabwe (UZ), as well as other PMTCT partners though the PMTCT Partnership Forum, have enabled EGPAF to develop sustainable and effective programs that have led to a massive reduction (and continued decline) in MTCT incidences.

By December 2014, the MTCT rate had already fallen dramatically to 6.7% at 18 months (cessation of breastfeeding). As of 2015, Zimbabwe had shown gains toward ensuring virtual elimination of MTCT.8 The project’s efforts over the past five years to overcome challenges in access to PMTCT services and HIV care and treatment among infants, children, and adults and to improve health program management in Zimbabwe have proved successful and are illustrated in detail herewith.

With future funding from donors and in collaboration with partners, EGPAF intends to sustain the impressive gains made in Zimbabwe and will help ensure that the country reaches its goal of reducing MTCT rates to less than 5%. This momentum will be sustained through groundwork for improving adherence and retention in care for HIV patients laid through EGPAF’s implementation of standard operating procedures (SOPs); continued maintenance of health care workers’ confidence in managing and monitoring patients on antiretroviral therapy (ART); and quality improvement to enhance programs that support patient ART retention and adherence and quality health services. It is EGPAF’s hope that this report will serve as a vessel to transmit the project’s promising practices in PMTCT and HIV care and treatment programming in Zimbabwe to settings or countries with similar hurdles to overcome.

In 2016 and thereafter, EGPAF-Zimbabwe will continue to monitor and sustain gains made in the PMTCT program by addressing quality-of-service provision, adherence, and retention issues in the context of Option B+. EGPAF will also continue resource mobilization efforts in order to assist the Zimbabwean government in addressing other remaining challenges in eliminating pediatric HIV and improving the quality of life of all people living with HIV and AIDS. EGPAF will be working to support the MOHCC in the coming years to accelerate pediatric ART in Zimbabwe. This effort will be made possible through funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and a multicountry grant from UNITAID.

Accelerating the Elimination of Pediatric HIV and AIDS in Zimbabwe: End-of-Project Report 9Accelerating The Elimination Of Pediatric Hiv And Aids In Zimbabwe: End-Of-Project Report 9


/ HIV AND AIDS IN ZIMBABWE /



The first AIDS case in Zimbabwe was identified in 1985, and by 1987, the prevalence of AIDS had risen to 3.2% of the population.5 Zimbabwe’s government was quick to work toward a solution, forming the National AIDS

Coordination Programme in 1987 and the National AIDS Council in 1999 to coordinate the national response to the epidemic. Despite national ambition, the country suffered from major shortages of both health care staff and HIV test and treatment supplies, all stemming from a lack of financial resources and commodities, thus hindering the national response to the epidemic. Life expectancy dropped from 59 years in 1980 to 43 years in 1995.6 By the late 1990s, the epidemic was concentrated mostly in rural areas and small towns, especially in the western and southwestern regions: Matabeleland North experienced an HIV prevalence rate of 18%, and Matabeleland South, an HIV prevalence of 21%. Urban areas reported an average 14.5% HIV prevalence rate.7

Zimbabwe is one of several countries in sub-Saharan Africa hardest hit by the AIDS epidemic, with an adult HIV prevalence currently of approximately 15%. However, the adult incidence rate decreased from 1.3% in 2011 to 1.1% in 2014.8,9 This progress can be attributed to the national HIV/AIDS prevention and treatment program, with the support of donors and global HIV program implementers. However, even as the percentage of infections among adults has decreased, the number of new infections among infants has remained high; in 2013, there were approximately 11,000 new infant HIV infections and 64,000 AIDS-related deaths among children.2

National adoption of the 2010 WHO PMTCT guidelines (Option A) in May 2010 helped Zimbabwe move closer to ending MTCT; in 2009, the MTCT rate was estimated to be approximately 30%, and by 2013, the rate had decreased to less than 9%. Scale-up of PMTCT service access resulted in 95% of health facilities in Zimbabwe offering PMTCT services. Zimbabwe was moving close to achieving universal PMTCT access with 78% coverage at population level and 94% uptake of PMTCT services among women attending antenatal care (ANC) in 2014. Since 2009, the proportion of new pediatric HIV infections has declined by 57%.7


In 2014, Zimbabwe transitioned to Option B+ of the 2013 WHO PMTCT guidelines, which recommended lifelong ART to all HIV-positive pregnant and breastfeeding women (regardless of CD4 count) and to all HIV-positive children of five years of age or younger.10 Successful national roll-out of Option B+, which was achieved in Zimbabwe in one year, further accelerated progress toward elimination of MTCT. The MOHCC worked with partners to ensure widespread access to Option B+ by integrating PMTCT services into all MNCH sites. ART is now initiated among HIV-positive pregnant and breastfeeding women within all MNCH sites throughout the country.7

With the successes in reduction of MTCT rates to approximately 6.7% by the end of 2014 (see Figure 1), the current focus for Zimbabwe is to accelerate the identification and treatment of HIV-infected children and adolescents.8 Universal treatment for children age five years or younger, as recommended by current global HIV guidelines, allows more permissive criteria to scale up pediatric ART. However, today, an estimated 121,111 children (0–14 years) living HIV in Zimbabwe are in need of treatment.22 HIV also remains a major underlying cause of childhood mortality, accounting for 21% of under-five mortality in Zimbabwe.6 Program implementers in the country are shifting focus from scale-up of PMTCT to sustainability of PMTCT, scale-up of early identification of HIV-infected children, and wider access to pediatric HIV care and treatment.

SPECTRUM ESTIMATE

2009

30%

HARVARD ESTIMATE

2011

18%

UCB BASELINE ESTIMATE

2012

8.8%

UCBEVALUATION

2014

6.7%

35%

30%

25%

20%

15%

10%

5%

0%

Figure 1. Steady fall in Zimbabwe’s national MTCT rate since inception of the CIFF/EGPAF partnership


/ EGPAF-ZIMBABWE /



EGPAF is a nonprofit organization dedicated to preventing pediatric HIV infection and eliminating pediatric AIDS through research, advocacy, and implementation of HIV prevention, care, and treatment programs. Founded in

1988, EGPAF works in 14 countries in sub-Saharan Africa and Asia, including Zimbabwe. With CIFF funding, EGPAF has been able to expand innovative PMTCT and HIV care and treatment services throughout Zimbabwe over the past five years.

Since 2001, EGPAF has been a lead partner to the MOHCC, supporting national PMTCT and pediatric HIV programs in Zimbabwe. By June 2015, EGPAF was providing direct support to 1,495 sites across 62 districts of Zimbabwe, representing 96% coverage of the 1,560 national ANC sites.

CIFF’s investment, together with complementary funding from the UK Department for International Development (DFID) and OPHID, enabled EGPAF to focus on PMTCT program scale-up and rapid geographic expansion in 2011 and 2012. The successful scale-up in the first two years of the CIFF award was followed by greater focus on the quality of comprehensive health services in supported sites and improvements in M&E systems, as well as substantial preparations for the national transition from WHO’s 2010 PMTCT guidelines to the 2013 PMTCT guidelines (Option B+) in subsequent years.

EGPAF played a key role in implementing both sets of WHO PMTCT guidelines (2010 and 2013) through an advisory role on the MOHCC’s PMTCT and care and treatment national working group committees. In this role, EGPAF was able to assist Zimbabwe’s government in making informed decisions on financial commitments (through input provided on costing and resource mapping exercises), site readiness to implement PMTCT guidelines, format and length of health worker trainings, clinical attachment and mentorship, and revision of training materials and M&E tools.

In 2016 and beyond, EGPAF will continue to support the MOHCC in scaling up identification of HIV-infected infants through a point-of-care (POC) early infant diagnosis (EID) grant from UNITAID and improving the quality of HIV service provision in selected districts through quality improvement (QI) initiatives funded through PEPFAR.


EGPAF’S TECHNICAL LEADERSHIP

CHILDREN’S INVESTMENT FUND FOUNDATION

EGPAF-Zimbabwe has provided technical expertise to Zimbabwe’s MOHCC throughout the program’s duration. The technical assistance provided includes supporting the MOHCC in training, clinical attachments, and clinical mentorship of nurses providing comprehensive HIV prevention, care, and treatment services and assisting with national HIV program scale-up strategies in MNCH settings.

Secondment of technical staff, including the National PMTCT and Pediatric HIV Care and Treatment Coordinator, national EID lab scientists, district focal persons, and data entry clerks, has been provided to the MOHCC. EGPAF also provides technical support to the MOHCC to develop updated M&E tools and to conduct evaluations and operations research to inform programming. EGPAF has a strong relationship with Zimbabwe’s Parliamentary Health Committee and has influenced policy decisions that affect public health through the development of appropriate policy briefs and

CIFF is an independent philanthropic organization, headquartered in London, United Kingdom, and with offices in Nairobi, Kenya, and New Delhi, India. The foundation collaborates with a wide range of partners that seek to transform the lives of poor and vulnerable children in developing countries. CIFF’s transformational work focuses on children’s and mothers’ health and nutrition, children’s education, deworming and welfare, and smart ways to slow down and stop climate change.

CIFF was established in January 2004 and set out to demonstrably improve the lives of children living in poverty in developing countries using strategies that have lasting

advocacy meetings. EGPAF provides technical experts to carry out assessments, provide recommendations, and develop materials (guidelines, training curricula, tools, job aids, etc.). Technical assistance initiatives supported in the past five years include the development of PMTCT training manuals aligned with 2010 and 2013 WHO guidelines, national PMTCT communications strategies, the national pediatric elimination plan for 2011–2015, the midterm review of the 2010–2015 elimination plan, and the new pediatric care and treatment acceleration plan. EGPAF provides technical support through training and commodity quantification, and it participates in the PMTCT and HIV Care and Treatment Partnership Forums and their subcommittees. EGPAF often lends its experts to support missions of the Inter-Agency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and Children, as in 2013, when EGPAF supported Zimbabwe’s MOHCC to develop an operational plan for transitioning to Option B+.

impact. Their approach focuses on data-driven methods to measure impact, which aligns with EGPAF’s mission and aims.

One of CIFF’s early program investments in children’s health was to increase treatment and care for pediatric AIDS in developing countries. Working with partners, including EGPAF, CIFF played a catalytic role in increasing the number of children who were properly treated for HIV. By underwriting the cost of children’s ARV medications, CIFF and other funders helped shape a market for a long-neglected area in children’s health. The result was to help reduce the wide disparity between the treatment of AIDS in adults and children.11


/ PROGRAM GOALS AND OBJECTIVES UNDER CIFF /

EACH YEAR OF

THE PROJECT HAD

SPECIFIC GOALS AND

OBJECTIVES THAT

GUIDED PROGRAM

IMPLEMENTATION:

2011GOAL GEOGRAPHIC EXPANSION OF THE COMPREHENSIVE NATIONAL PMTCT PROGRAM BASED ON THE 2010 WHO GUIDELINES

OBJECTIVESScaling up health care worker recruitment and procurements

Sensitization of national and local officials, implementing partners, facilities, communities, and beneficiaries to ensure the scope of the PMTCT program had strategic input and buy-in from all key stakeholders

Planning for and rolling out a number of critical new program interventions

Supporting the revision of key MOHCC strategies, national training curricula, and M&E tools

Putting in place the necessary operations to successfully manage and oversee this expanded program

2012 GOAL CONTINUED PROGRAM SCALE-UP AND IMPROVEMENT IN THE QUALITY OF EXPANDED PMTCT SERVICES

OBJECTIVESCapacity building of health care providers (including training, post‐training follow-up, targeted site supportive supervision, and mentorship)

Introduction of QI activities

The overall goal of CIFF’s investment in Zimbabwe’s PMTCT program was to reduce the rate of MTCT from an estimated 30% in 2010 to less than 12% by 2015.1 CIFF’s award helped EGPAF scale up PMTCT services to 1,495 health facilities in Zimbabwe by June 2015 and train more than 12,000 health care workers in quality PMTCT and HIV care and treatment delivery, in line with national guidelines.*


/ PROGRAM GOALS AND OBJECTIVES UNDER CIFF /

2013 GOAL PREPARE ZIMBABWE FOR THE NATIONAL TRANSITION FROM OPTION A TO OPTION B+ OF THE WHO GUIDELINES FOR PMTCT

OBJECTIVESProviding the MOHCC with high-level technical assistance, ensuring informed policy development and implementation of revised PMTCT guidelines

Adapting WHO 2013 guidelines to Zimbabwe’s priorities and subsequently revising the communication strategy around the revised guidelines, the site assessment tool, SOPs, and M&E tools to reflect the new guidelines

Developing job aids, new training curricula, and information, education, and communication materials

Continuing training, mentorship, site support, and supervision

2014 GOAL ENSURE CONTINUED ROLL-OUT OF OPTION B+, THEREBY SCALING UP GREATER ACCESS TO ART AMONG HIV-POSITIVE WOMEN AND CHILDREN

OBJECTIVESEnsuring that all supported ANC facilities offer quality ART, including pediatric ART services within MNCH clinics, by December 2014

Providing national, provincial, and district-level technical assistance, thus supporting the MOHCC with critical Option B+ roll-out activities

2015 GOAL OPTIMIZE THE EFFECTIVENESS OF THE PMTCT PROGRAM TO MAXIMIZE HIV-FREE SURVIVAL AT 24 MONTHS

OBJECTIVESMaximizing and sustaining the gains in PMTCT along the PMTCT cascade

Laying the groundwork for pediatric HIV diagnosis, treatment, and retention scale-up along the pediatric cascade

Enhancing program management, documentation, transition, sustainability, and award closeout

*The number of health care workers trained may reflect some double counting if the same worker received trainings on different topics.


/ ACHIEVING INCREASED NATIONAL COVERAGE OF PMTCT /

MASVINGO

BULAWAYO

MATABELELANDNORTH

MATABELELANDSOUTH

MIDLANDS

MASHONALANDWEST

MASHONALANDEAST

MASHONALANDCENTRAL

MANICALAND

HARARE

EGPAF-supported regions



/ ACHIEVING INCREASED NATIONAL COVERAGE OF PMTCT /

MASVINGO

BULAWAYO

MATABELELANDNORTH

MATABELELANDSOUTH

MIDLANDS

MASHONALANDWEST

MASHONALANDEAST

MASHONALANDCENTRAL

MANICALAND

HARARE

EGPAF-supported regions

Since the program’s inception, EGPAF-Zimbabwe has been a primary partner of the MOHCC, providing technical support to increase access to comprehensive, high-quality PMTCT services and HIV/AIDS care and treatment

support to families. Through CIFF’s investment, EGPAF expanded its partnership with the MOHCC, which allowed implementation of district-level activities strengthening each district’s approach toward PMTCT and pediatric HIV service delivery. In addition, the expanded support has ensured greater constructive efforts to increase demand for, use of, and retention in PMTCT services. Figure 2 depicts EGPAF’s support of all regions in Zimbabwe.

DEVELOPING A MODEL OF SERVICE DELIVERY SUPPORT: DISTRICT INVOLVEMENT IN PMTCT Before the launch of CIFF-funded activities, EGPAF began developing a district approach model in Zimbabwe in 2004, wherein EGPAF subgranted funds directly to districts to support HIV service implementation, instead of directly providing support and services to sites. This strategy promoted public-sector sustainability and enabled district leaders, managers, and health care providers to assume greater responsibility and accountability for program results, allowing them to manage, implement, and monitor integrated HIV clinical services.

In 2011, to address the ongoing challenge of health care worker shortages, EGPAF—in collaboration with the MOHCC and district leaders and with financial support from CIFF—adopted and nationalized a district focal person (DFP) model to support Zimbabwe’s national PMTCT program within its district-based approach. EGPAF hired 37 DFPs to cover all districts in Zimbabwe, with each DFP covering two districts. The permanent secretary of the MOHCC provided guidance on the recruitment of DFPs, with each being recruited collaboratively by EGPAF and the provincial medical director representatives for selected provinces.

DFPs are experienced community health nurses (registered nurses or midwives) based within districts. They are charged with supporting the MOHCC district health management teams (DHMTs) in implementing the revised 2010 and 2013 WHO PMTCT guidelines. The DFPs were recruited from the districts to which they were assigned to ensure that they are familiar with the districts and the DHMT. EGPAF, with the MOHCC, provided each DFP with comprehensive training on current guidelines and guidance on provision of technical assistance support, a new vehicle for transport to and from health facilities, and a schedule to maintain. Each DFP is expected to conduct supportive supervision visits to each health facility in his or her supported districts once per quarter.

In their roles, DFPs continuously monitor and strengthen the capacity of the district nursing officers (DNOs) and DHMTs and provide support to facility-based health care workers to strengthen delivery of PMTCT services at the lower facility level.


The DFPs routinely collect program management indicator (PMI) data on the availability of services such as HIV test kits, ARVs, and interruptions on service availability. The PMIs are then used to inform areas of focus for program strengthening during DFP/district health executive (DHE) site support visits. The DFP model creates a framework for immediate scale-up of and improvements in PMTCT delivery, including increased health facility staff accountability for PMTCT delivery, PMTCT register completeness, and an increased understanding of what is happening at the site and district levels (and subsequent support needed) among program implementers and the MOHCC. DFPs are also instrumental in supporting the assessments and providing capacity building to sites, ensuring full implementation of Option A and Option B+.

Although the capacity of DNOs and the DHMT to manage PMTCT service has been strengthened, human resource gaps still exist at the district level, particularly with the recent shift in guidelines from Option A to Option B+. The DFPs are therefore still regarded as an integral resource in ensuring that the quality of HIV services is improved and that the gains made in the PMTCT program are maintained and strengthened. The MOHCC has fully endorsed the role and use of DFPs in the national PMTCT program and has committed to providing continued support in 2016 for this model to support broader QI initiatives.

NATIONAL PMTCT GUIDELINE IMPLEMENTATION2010 WHO PMTCT GUIDELINE IMPLEMENTATIONIn 2010, the WHO published a new set of guidelines recommending greater access to more effective PMTCT regimens. These guidelines recommended lifelong ART for women who require it for their own health (disease progression as determined by their CD4 count) and longer duration of more efficacious ARV regimens for all other HIV-positive pregnant women.3 EGPAF supported a consultative process to adapt and adopt the WHO 2010 PMTCT and ART guidelines and to revise related training materials.

In January 2011, Zimbabwe’s MOHCC launched an agenda to eliminate new HIV infections in children and keep mothers alive. Implementation and nationwide roll-out of the revised WHO guidelines served as a catalyst to reach the elimination targets by 2015. To facilitate the roll-out, health care staff were trained in the 2010 WHO guidelines to ensure a rapid, efficient process. At the national level, 30 trainers from all provinces and cities were trained. Provincial trainings were then conducted for 237 health workers representing all districts in the eight provinces.

In May 2011, EGPAF conducted a situational analysis of Zimbabwe’s PMTCT program at 1,317 sites. The analysis revealed that the revised national 2010 PMTCT guidelines had been implemented only in 124 sites, while 851 were still following the WHO’s 2006 PMTCT guidelines. The results from this analysis assisted the MOHCC and EGPAF to further scale up training on the 2010 PMTCT guidelines throughout 2011, using a national training program supported by EGPAF and implemented by EGPAF’s subgrantees, including JF Kapnek Charitable Trust, OPHID, and ZAPP-UZ. By the end of September 2011, a total of 3,775 health workers had been trained in rapid HIV testing, initiation of prophylaxis and treatment under the WHO’s 2010 guidelines, M&E, and infant and young child feeding in the context of HIV. Because this training also integrated EID training manuals, this program trained participants on EID provision. Through this support, the number of sites implementing the current WHO PMTCT guidelines (2010 and 2013 guidelines) increased to 1,495 by June 2015. Sites offering EID services also rapidly increased (see Figure 3). DHE members, DFPs, and program partners subsequently conducted site-level, post-training support and supervision for ongoing mentorship of trained cadres.

2013 WHO PMTCT GUIDELINE IMPLEMENTATION The WHO released a programmatic update in April 2013 recommending that countries move toward providing ART to all HIV-positive pregnant and breastfeeding women for life (Option B+), regardless of CD4 measurements.12 In response, Zimbabwe’s MOHCC AIDS and Tuberculosis Unit convened a national stakeholder consultation in February 2013, which resulted in the decision to transition to Option B+.

The MOHCC requested external technical assistance from the United Nations Inter-Agency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and Children (IATT) to help develop a national operational plan to implement Option B+. The IATT secretariat formed a technical assistance team with EGPAF and the U.S. Centers for Disease Control and Prevention (CDC) to respond to this request. In July 2013, the technical assistance team conducted a rapid desk review of relevant background documents and policies guiding the implementation of the national PMTCT program. The team proposed a framework for the Option B+ operational plan organized around the seven strategic objectives of Zimbabwe’s National Strategic Plan for Elimination of New Pediatric HIV Infections; it drafted illustrative outputs with proposed activities for each operational area.13

The MOHCC convened a series of stakeholder meetings to gather input on the operational plan framework, which was officially endorsed by the MOHCC and launched in November 2013.


EGPAF-Zimbabwe was tasked with managing and ensuring the expedited roll-out of Option B+ in 2014. Through CIFF-provided funds, EGPAF was able to assist the MOHCC in accomplishing the complex and rapid roll-out within one year. Specific EGPAF-led activities included supporting the adaptation of WHO 2013 guidelines to the national context and developing updated training curricula; M&E tools; job aids; and information, education, and communication (IEC) materials. EGPAF also assisted in training health care workers on the new guidelines and streamlined the ART site capacity assessment tool—a tool used to gauge sites on their preparedness to offer lifelong ART under these new guidelines (results were used to align preparations and site needs). Through the DFPs, EGPAF supported the site assessments and capacity-building exercises in all districts, using the updated site assessment tool. The DFPs also provided post-training site support and supervision. This resulted in a rapid increase in sites offering Option B+, as shown in Figure 4.

INCREASING PMTCT DEMAND, USE, AND RETENTION PMTCT DEMAND GENERATIONCreating demand for PMTCT services became a priority for EGPAF under CIFF’s award. In order to scale up the elimination of mother-to-child HIV transmission, EGPAF realized a great need to ensure education and buy-in around PMTCT services among the general population. PMTCT demand was generated through several activities, including use of operations research (OR) studies to better understand barriers and facilitators to PMTCT access, use of communications platforms to increase general knowledge of PMTCT among Zimbabwe’s population, and implementation of community dialogues to address barriers to PMTCT service uptake.

One partner-led study in 2011, conducted in Harare, Manicaland, Mashonaland Central, Matabeleland South, and Mashonaland West, found significant gaps in the uptake of MNCH services: Nearly 36% (3,130/8,662) of women did not attend the four WHO-recommended ANC visits, 74% (6,444/8,662) delivered in a health facility, and, among women who tested HIV-positive before or during delivery, 70% (696/997) reported ART or ARV prophylaxis use.14 These results underscore a need to ensure greater demand for and access to PMTCT throughout the country.

2011

1,600

1,400

1,200

1,000

800

600

400

2002012 2013 2014 2015

Figure 3. Trends in EGPAF-supported MNCH facilities offering PMTCT, EID, and ART services on-site, 2011–2015

EGPAF-Supported Sites Offering EID On-Site

EGPAF-Supported Sites Offering ART Services On-Site

EGPAF-Supported Sites Offering PMTCT Services According to Current WHO Guidelines


EGPAF used OR to delve into facilitators and barriers to PMTCT service use. From 2010 through 2013, EGPAF-Zimbabwe examined barriers such as poor infrastructure, increased transport costs, health care worker attitudes, and fees for use of PMTCT services; it then mitigated some of these barriers in subsequent years of PMTCT service scale-up implementation under CIFF’s award. EGPAF examined facilitators, such as peer-facilitated community support groups for pregnant and postpartum women and the EGPAF-supported village health worker (VHW) program. These community groups, coupled with additional support to the VHW program (including bicycles, uniforms, training on PMTCT, SOPs for patient tracking and tracing, and printing and supplying VHW registers and reporting tools), helped decrease mean gestational age at ANC booking by two weeks. In the peer-to-peer study, the percentage of women booking at less than 21 weeks gestation increased by 11%, and the percentage of women attending all four (or more) recommended ANC visits increased by 15%.15 The evidence from these studies was used to inform the national retention strategy, which was scaled up with support from the MOHCC and other implementing partners. Findings were also used to increase

PMTCT demand through the use of mainstream media. Data from the electronic database, which was piloted by EGPAF with the MOHCC in 36 health facilities across the country, showed that mean gestational age at booking continued to decline and the proportion of pregnant women booking before 21 weeks gestational age continued to increase from 2011 to 2015 (Figure 5).

In 2011, EGPAF-Zimbabwe supported the MOHCC to hold a two-day national capacity-building workshop for 30 health media correspondents from local print and electronic newspapers. This workshop aimed to ensure media practitioners had accurate knowledge and awareness of the importance of PMTCT, key facets of the revised WHO 2010 PMTCT guidelines, and background information on the national elimination plan. Not only did this involvement of media correspondents result in a more effective partnership between media and key HIV program-implementing organizations (resulting in three follow-up trainings for media practitioners throughout subsequent years), but also the country’s three main daily newspapers featured stories on the elimination of new pediatric HIV infections. EGPAF also provided content and messaging for a popular radio program that hosted a 13-part radio

2011Q3

2011Q4

2012Q1

2012Q2

2012Q3

2012Q4

2013Q1

2013Q2

2013Q3

2013Q4

2014Q1

2014Q2

2014Q3

2014Q4

2015Q1

2015Q2

1,600

1,400

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Figure 4. Trends in MNCH sites offering Option A and Option B+ from the third quarter of 2011 (July–September) to the second quarter of 2015 (April–June)


series devoted to HIV (including discussions of risk behaviors, prevention, PMTCT, care, and treatment) directed at and involving youth listeners via text messaging. High participation was noted through call-ins and SMS text messaging.

Over the past five years, EGPAF provided the MOHCC with support for both the National Advocacy and Communications Strategy for Elimination of New HIV Infections in Children and the Keep Mothers Alive plan. EGPAF-Zimbabwe also hosted the highly visible National HIV and AIDS Conference in September 2011, which provided much-needed media attention around HIV/AIDS, as well as the need to ensure greater access to PMTCT and HIV care and treatment services.

In addition to mass media activities, EGPAF engaged in more targeted approaches to ensure expansion of PMTCT service uptake in rural areas at the community level. Zimbabwe’s 2010–2011 Demographic Health Survey showed that 65% of births occurred in health facilities, highlighting an area for increased focus in PMTCT service uptake improvement. Facility deliveries provide a critical opportunity to test, counsel, and treat women for HIV.16

Manicaland Province was targeted for community stakeholder dialogues due to its high home delivery rates (36% of deliveries occur at home). Six community dialogues were held with 4,000 community leaders and residents in five districts within the province. Through these dialogues, local leaders committed to supporting PMTCT service uptake and created a more supportive environment for women to deliver in facilities by building lodging near facilities for expectant mothers and raising resources to increase dialogues to counteract religious and cultural objections to facility deliveries.

In 2012, as part of preparations for the peer-facilitated, community-based support group study, 304 community leaders from 254 villages in Hurungwe district were recruited to attend eight EGPAF-led dialogues on supporting PMTCT and providing PMTCT education within their own communities. To improve general knowledge, EGPAF created and distributed to attendees flyers and brochures on key facts related to MNCH, HIV, and PMTCT. One outcome of these trainings was the development of community support groups for pregnant women throughout the district.

Jan-Dec 2012 n= 17,736

Jan-Dec 2013 N= 23,191

Jan-Dec 2014 N= 22,083

Jan-Jun 2015 N= 9,173

30 100%

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ATIO

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E (W

EEKS

)

% B

OO

KING

<=1

4 W

EEKS

% BOOKING AT OR BEFORE 14 WEEKSMEAN GA AT BOOKING

Figure 5. Gestational age (GA) at ANC booking and proportion booking for ANC before 14 weeks gestational age Source: Data from 36 EGPAF-supported sites.


Overall, strengthened demand generation and improved community participation, coupled with improvements in PMTCT services and EGPAF’s targeted messaging on the importance of early ANC visits (highlighted in Figure 5), may have played a critical role in increased population-level coverage of PMTCT service delivery nationally, from 9% in 2009 to 78% in 2014.17

INCREASED USE OF PMTCT SERVICESAs demand for services increased, improved service delivery capacity became essential. Several EGPAF-led projects from 2010 to 2015 focused on improvements in PMTCT service delivery, including implementing POC CD4 diagnostic technology to improve access to CD4 testing and results, thereby increasing the number of women determined eligible to initiate treatment under the 2010 WHO PMTCT guidelines. In addition, activities such as task shifting and trainings of health care workers were implemented to ensure greater access to trained health workers among women and children.

From 2010 to 2013, under the 2010 WHO PMTCT guidelines, determining the CD4 T-lymphocyte count of people living with HIV was critical for accurately determining their eligibility to initiate long-term ART. Evaluation of ART eligibility can prove extremely challenging in resource-limited settings, where access to laboratory-based CD4 analysis is limited and laboratory technicians are overburdened. Traditionally, pregnant women who tested HIV-positive in MNCH settings in Zimbabwe were referred to ART clinics, where they received CD4 testing in order to be initiated on treatment. For women who completed the referral process, result turnaround time, from blood draw to return of results to the client, could take several weeks. As a result, many treatment-eligible women in Zimbabwe were never initiated on ARVs or ART, or they were initiated late. In addition, the lack of an explicit national policy in Zimbabwe allowing nurses to initiate ART was a major barrier to ART initiation in MNCH settings, as trained doctors had little time to ensure that every woman eligible for treatment was counseled and initiated on ART.

Between April 2011 and June 2012, EGPAF provided 154 POC CD4 machines to the MOHCC. The first batch of 50 machines procured in 2011 was deployed to 50 high-volume MNCH facilities, with the specific aim of ensuring a greater number of HIV-positive women were assessed for ART eligibility. Between July 2011 and March 2012, 6,117 MNCH clients received POC CD4 testing. This included 3,943 HIV-positive pregnant women tested in ANC, as well as 1,747 postnatal women and 427 male partners of MNCH clients. An additional 1,853 non-MNCH clients attending ART clinics at the same facilities received POC testing during this period, which highlights the important secondary use of the analyzers as back-up testing mechanisms for clients from other clinics. The

second batch of 104 POC CD4 machines procured in 2012 was deployed to the next 104 high-volume MNCH settings. The use of POC CD4 technology increased the number of women identified as eligible for ART; a 100% increase in the number of HIV-positive women screened for ART eligibility was observed through this program (Figure 6).

The 2013 WHO PMTCT guidelines removed the need for baseline CD4 monitoring to enable quicker access to treatment; however, CD4 monitoring remains a viable method for assessing the response to ART in the absence of viral load testing. Thus, EGPAF continues to reinforce the importance and effective use of CD4 monitoring during supportive site supervision. Currently, most of the POC machines placed in these supported sites are being used for treatment monitoring for both pregnant HIV-positive women and the general public. EGPAF has monitored use of the 154 POC machines procured through CIFF funding. In the April to June 2015 quarter, 8,819 patients were CD4 tested, of which 840 (10%) were pregnant women, 415 (5%) were postnatal women, 110 (1%) were male partners of pregnant women, 6,986 (79%) were general adult opportunistic infection (OI) / ART patients, and 468 (5%) were children younger than 15 years. Of the 8,819 CD4 tests conducted, 2,574 (29%) were baseline tests, and 6,245 (71%) were tests used to monitor patients.

The adoption of the 2010 and 2013 WHO PMTCT guidelines and the availability of POC CD4 machines in MNCH resulted in more women being identified as eligible for ART initiation within MNCH settings. According to the MOHCC, the need to initiate 40%–50% of HIV-positive pregnant women on ART under the 2010 guidelines (and 100% under the 2013 guidelines) could not be met by the centralized, doctor-led, vertical ART program in Zimbabwe because not enough doctors are available to ensure scale-up. This highlighted the need for task shifting of ART initiation to other health workers. To strengthen task shifting and nurse-led ART initiation among pregnant women, breastfeeding women, and children, nurses needed to be trained in OI and ART management. To address this need and build capacity, trainings in OI/ART for nurses were conducted, and a clinical mentorship program was employed to provide in-service mentorship, improve quality of services, and improve health care provision. In addition, in the absence of nurse-led initiation, POC CD4 machines were used to promote ART initiation.

Through enhanced use of POC technology and task shifting, continued expansion of the PMTCT program occurred throughout Zimbabwe. These activities led to an increase in the number of women initiated on ART and an increase in the number of health providers available for counseling, testing, and treatment per the revised guidelines. In 2011, 39,091 (86%) of the estimated 45,623


ANC BOOKINGS AZT PROPHYLAXIS ART INITIATION - MOTHERS INFANT NEVIRAPINE

HIV TESTING CD4 TESTING ART RETENTION - MOTHERS EID

HIV-positive pregnant women received ARVs for PMTCT. Of these, only 16% received ART for their own health, even though program data from sites with POC CD4 machines suggest that the proportion of pregnant women eligible for ART should be approximately 50%. By 2014, with the transition to Option B+ and increased health care provider capacity for ART initiation, the proportion of HIV-positive women initiating lifelong ART increased from 50% (5,248/10,400) to 95% (7,769/8,176) over the course of the year. Overall, indicators along the PMTCT cascade increased markedly in the EGPAF-supported sites during the five-year implementation period (see Figure 6).21

IMPROVEMENTS IN RETENTION IN THE PMTCT CASCADERetention of women and children on ART to ensure viral load suppression and realize the benefits of Option B+ has long been a challenge for service providers in Zimbabwe. In partnership with CIFF and the MOHCC, EGPAF-Zimbabwe implemented activities to monitor and improve retention through the implementation of an

electronic database (EDB) and tracking system, as well as improved community linkages, which included use of DFPs. In 2013, EGPAF-Zimbabwe supported the MOHCC to assess site-level retention and treatment adherence among HIV-positive pregnant women and HIV-exposed and -infected infants. This assessment revealed that ARV prescription collection by women on ART dropped from 31% by the second scheduled ARV pick-up from the health clinic to 7% by the ninth scheduled pick-up. Collection of nevirapine (NVP) among HIV-exposed infants’ caregivers at assessed sites dropped from 44% at the second pick-up to 9% by the eleventh scheduled pick-up. ARV collection among infant caregivers on ART dropped from 46% at the second scheduled pick-up to 6% by the tenth scheduled pick-up.18 Ensuring ART retention among these groups was clearly an area of need for effective implementation of Option B+.

201220112010 2013 2014 2015

100

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ENTA

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F UP

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Figure 6. PMTCT service uptake in EGPAF supported sites, 2010–2015 AZT = zidovudine


In 2014, EGPAF trained 37 DFPs in Option B+ and ART retention and coached 125 EGPAF-supported, facility-based health care workers across 62 districts to improve retention through the use of SOPs, including job aids and appointment diaries, and the use of VHWs to track clients in the community. Between April and December 2014, the use of appointment diaries among health worker staff to better track and follow clients who missed their appointments was rolled out. The proportion of women

and children retained on ART six months post-ART initiation increased, and the proportion of sites with retention rates above 90% for women increased from 46% before the training and various activity implementation to 66%. Six-month retention of children had surpassed the 90% target by June 2015 (see Figure 7).

Because of their initial success in improving retention post-training, EGPAF introduced appointment diaries in all MNCH

JAN FEB MAR APR MAY JUNE

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AT 6

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Figure 7. Retention of women initiated on ART during pregnancy in 115 sites and infants initiated before two years of age after six months of treatment in 81 sites Source: EGPAF data from sites implementing QI activities on client retention in PMTCT, January–June 2015.

93%

75%74%72%72%

69%

60%


MOTHERS’ RETENTION


sites throughout the country to better enable health care providers to identify and follow up with patients who missed their clinic appointments by more than three days. After the first follow-up attempt, health workers were informed to delegate follow-up to a community health worker or ensure a phone call was placed to the client. In 2013, to further improve retention in advance of Option B+ implementation, EGPAF developed SOPs and M&E tools for tracking and tracing mother-baby pairs to enhance long-

term adherence support and to optimize patient retention in care. These SOPs, which have been adopted nationally, were rolled out by the MOHCC and incorporated into the national VHW training curriculum.

Using CIFF funds, EGPAF-Zimbabwe pioneered several initiatives to improve service delivery, build health care worker capacity, and track patients to improve retention in care. EGPAF supported the MOHCC to strengthen the management and coordination of the national PMTCT and pediatric HIV care and treatment program by using an innovative model of service delivery that integrates ART provision for HIV-infected pregnant and breastfeeding women and HIV-exposed and -infected infants in MNCH facilities. Through this model, EGPAF builds the capacity of health care workers to improve service delivery and provide integrated, comprehensive, high-quality HIV prevention, care, and treatment services in MNCH units for mothers and babies. Specific support includes training of health care workers on HIV management and providing clinical mentorship to build the confidence of health care workers to initiate and manage lifelong ART for mothers and babies in MNCH settings.

EGPAF works to link HIV-positive women, children, and families to wraparound services, such as nutritional support, malaria and TB prophylaxis and treatment, OI prophylaxis and treatment, routine immunizations, and psychosocial support. By the end of 2015, HIV and MNCH services were integrated into all MNCH sites.

The model is critical to accelerating efforts to eliminate pediatric AIDS. It has been successful in increasing ARV coverage in ANC nationally from 55% in 2011 to 95% in 2015, enhancing long-term adherence support, optimizing patient retention in care, preventing more than 37,000 infections in children, and averting more than 13,000 deaths in children ages 0–4 years.19

INNOVATION: SERVICE INTEGRATION

Accelerating The Elimination Of Pediatric Hiv And Aids In Zimbabwe: End-Of-Project Report 29


/ ACCELERATING PEDIATRIC ART /



Effective and efficient pediatric HIV diagnosis, treatment, care, and support services give an HIV-infected child a chance at a long and healthy life; 50% of HIV-positive children will die in the absence of treatment before their

second birthday. Since 2009, there has been a 57% decrease in the number of new HIV infections among children in Zimbabwe.7 However, despite current gains in PMTCT and MNCH scale-up and use in Zimbabwe, pediatric ART coverage remains a challenge. In 2013, there were 9,000 new HIV infections among children, and only 27% of children living with HIV had access to ART.8,14 One of the major contributing challenges to reaching the elimination goal in Zimbabwe has been low uptake of EID.

EGPAF worked to strengthen EID by focusing on improving the quality of EID services provided, as well as increasing access to, and awareness of, the importance of EID. Specific support included training health staff to offer these services, strengthening the national sample transportation system through use of a courier for sample and result transportation, and improving EID human resources at the national level through provision of three seconded, Roche-certified lab scientists at the National Microbiology Reference Laboratory. Through these interventions, the number of children less than 2 years initiated on ART increased as shown in Figure 8.

Despite this increase, there remains a gap between pediatric and adult ART coverage in Zimbabwe. In 2014, pediatric ART (<15 years) coverage was estimated at 39% compared to 51% among adults (>15 years) [denominator – total HIV population in each age group].

CLINICAL MENTORSHIP IN PEDIATRICSEGPAF’s clinical mentorship program, initiated in 2012, focused on training nurses and doctors on advanced HIV management, especially for infants and children, thus building the capacity of the nurses and doctors to initiate pediatric patients on treatment early. The program provides an attachment training wherein nurses are sent to centers of excellence to learn from experienced health care providers, followed by a return to their own facilities to receive in-service mentorship by EGPAF-trained mentors. This HIV management training program has built the capacity of 139 doctors and 718 nurses to initiate children on treatment and effectively manage pediatric HIV treatment.

FASTER TURNAROUND TIME OF EID RESULTSA study conducted by EGPAF on EID result turnaround time (TAT) in 2013 showed that only 16% of EID results were received by caregivers within four weeks of testing (the national standard). When further assessed, national laboratories voiced the need for additional data entry clerks to speed up the entry and coding of samples, where the largest delay in TAT was noted.20


In 2013, the government of Zimbabwe decentralized the national lab, and two regional EID laboratories were opened in Mutare and Bulawayo, thus ensuring that overburdened labs were alleviated and increasing the speed of diagnostic processing. This enhanced EID processing at a national level. Furthering these national efforts, EGPAF-initiated programs focused on EID result TAT (Figure 9). EGPAF began working with Courier Connect and with FedEx in 2013 to reduce transportation time between central collection points

and all peripheral sites. FedEx helped expedite transport between central areas near community health centers and laboratories for processing.

In late 2014, EGPAF began providing technical and financial support to the MOHCC to conduct a detailed assessment of the timeframe for the standard EID process, from sample collection to receipt of results. The overall TAT post-implementation of these

MAR 2012

MAR 2013

MAR2014

MAR 2015

2,880

Figure 8. Cumulative number of children (<2 years) initiated on ART by year, March 2012 to March 2015

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13,735



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various EID-strengthening initiatives improved to a 10.1 week average in the 2014 assessment, down from 15.9 week average in the 2013 assessment. In addition, the median time from dispatch of results from the laboratory to clients has reduced from 6.0 weeks to approximately 2.6 weeks. This assessment also found that part of the low performance on the percentage of infants given EID results in the routine health management information system is due to poor documentation of results given to clients. From a total sample of

specimens assessed in the EID TAT study, only 40% were recorded as given to clients.20 However, results often were given to clients but not recorded. Strengthening documentation around EID has thus been a recent priority for EGPAF and has been addressed through site-level QI activities involving verification of indicators collected by staff managers.

2010 2011 2012 2013 2014

16,481

Figure 9. Number of DNA polymerase chain reaction (PCR) samples tested in EID labs, 2010–2014

38,155

47,733

55,24050,498



/ DEVELOPING OPTIMAL M&E SYSTEMS /



Developing an optimal M&E system was a top priority for EGPAF and proved to be a critical component to the successful scale-up of PMTCT and HIV care and treatment in Zimbabwe. EGPAF strengthened

national M&E efforts and participated in the planning and implementation of the MOHCC’s PMTCT program evaluations, including support for the development of protocols, data collection and analysis, and client satisfaction surveys. EGPAF-Zimbabwe’s work at the national level included examining the completeness and accuracy of data in Zimbabwe’s national PMTCT program health facility registers and use of the critical path (see Figure 10) for rapid expansion and optimization of a PMTCT program.

STRENGTHENING DATA QUALITYBoth CIFF and EGPAF promote evidence-based program management and improvement. Inadequate health management information services and poor data quality impair not only the ability of clinicians to provide quality care but also the ability of policymakers to introduce responsive national policies. In 2011 and 2012, EGPAF’s major M&E activities included revising, printing, and distributing M&E tools and job aids, as well as training staff in M&E. EGPAF supported the development of an M&E training manual, an indicator guide chart, and a frequently asked questions booklet on PMTCT indicators and collection. In addition, EGPAF trained more than 800 health care workers in 22 districts on data collection and analysis.

In the second half of 2012, EGPAF focused more heavily on introducing and integrating QI initiatives within the PMTCT and MNCH program areas, as well as on supporting the development of the MOHCC’s national QI strategy. In early 2012, EGPAF-Zimbabwe developed and rolled out a QI initiative to improve the quality of the provision of pediatric ART services and PMTCT and ART in MNCH settings, aiming to optimize care for HIV-positive pregnant and breastfeeding women and their HIV-exposed or -infected babies. Specific support included QI-oriented site support visits to all EGPAF-supported sites at least once per quarter and clinical ART mentorship for 103 sites from seven provinces.

From October 2012 to January 2013, EGPAF reviewed its own data use in supported sites and districts, developed a data-use plan for its program, and initiated quarterly evidence-based program reviews to enhance data use for decision making in the program. To develop the data-use plan, EGPAF reviewed existing data-use constraints, planned solutions, and identified key program questions to be answered using routine program data (e.g., the proportion of sites offering, and the proportion of clients receiving, different PMTCT services). In January 2013, EGPAF introduced the quarterly evidence-based program reviews, which included 30 participants, including program managers, technical officers, and M&E officers, from MOHCC and EGPAF partners.


The meetings provided an opportunity for program data from the previous quarters to be discussed and served as a venue to identify challenges and improve quality program implementation.

In response to the revised 2013 WHO guidelines, CIFF, EGPAF, and the MOHCC developed a “critical path”—a prioritized set of performance indicators, with population-based targets, that are the main drivers of impact. If performance lagged in a particular indicator, direct, corrective action was explored.

Through use of the critical path cascade, EGPAF and CIFF supported the MOHCC to achieve a rapid scale-up of PMTCT services. Figure 10 provides an example of the critical path for 2013 targets (featuring scale-up of PMTCT under Option A). The foundation of the critical path allowed for a speedy scale-up of the Option B+ guidelines. By October 2014, EGPAF was supporting 1,480 out of 1,560 PMTCT sites in the country to provide Option B+.

EGPAF pioneered use of the EDB for enhanced

PMTCT service functions in Zimbabwe. This

system was created to tackle the challenge

of longitudinal patient tracking in a paper-

based system, which was the system in place

in Zimbabwe in 2011. In October 2011, EGPAF-

Zimbabwe began supporting the MOHCC

in piloting the EDB to enhance longitudinal

follow-up of clients receiving PMTCT services.

Starting in March 2012, the EDB was piloted at

36 facilities in five districts, in both rural and

urban areas. Facilities were selected by the

MOHCC for the pilot based on their high volume

of ANC attendees. EGPAF recruited and trained

20 data entry clerks to assist in the transition to

the EDB from paper-based registers at assigned

sites. The EDB proved to be a valuable tool for

addressing loss to follow-up challenges and

helped identify and track patients who had missed appointments.

The pilot program was met with satisfaction, particularly among health workers who were now understanding (through this mechanism) how women were accessing care, prophylaxis, and treatment in ANC. Challenges, such as the mobility of the population they were serving, low ANC booking at less than 14 weeks gestation, and poor follow-up prophylaxis collection, were now noticed and rectified. Important lessons were learned from development and scale-up of the EDB and have informed the development of the MOHCC national electronic patient-monitoring system. (To date, this national e-PMS has been rolled out to 246 sites toward a 2016 target of 534 sites.)

INNOVATION: ELECTRONIC DATABASE



IMPACT: REDUCE MOTHER-TO-CHILD TRANSMISSION TO 12%

HIV TESTING, ARVS FOR HIV+ PREGNANT WOMEN (YEAR 3, QUARTER 2) INFANT TESTING AND PROPHYLAXIS (YEAR 3, QUARTER 2)

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9,64895%

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97%

103,03892%

Figure 10. Graphical presentation of the critical path used during Option A



/ HEALTH SYSTEMS STRENGTHENING /



Existing HIV services and the capacity to further scale up HIV services in Zimbabwe are constrained by an insufficient number of qualified, motivated, and appropriately dispersed health workers. Weak systems

and a lack of capacity to effectively plan for, manage, and identify human resource needs have resulted in staff shortages, underqualified health staff, and poor patient care in Zimbabwe.

TECHNICAL ASSISTANCETo strengthen the health workforce, EGPAF addressed health system weaknesses at multiple levels, including secondment of staff at the national level, training of regional teams and DHMTs to assess staff needs, and mentoring of lower-level facilities to effectively manage human resources. As part of CIFF’s and EGPAF’s commitment to ensure sustainable HIV services, EGPAF-Zimbabwe worked with the MOHCC to build managerial, administrative, clinical, and operational capacity to strengthen the health system. EGPAF provided comprehensive technical assistance (in the form of national technical working group participation, wide-scale trainings, and clinical mentorship) to national and decentralized health authorities to contribute to gradual increases in country ownership of the HIV response, an area in which the Zimbabwe government excels. From 2011 to 2015, EGPAF trained 12,964 health care workers in various technical topics, of which about 60% were trained using CIFF resources (with the remainder trained using other leveraged donor funding).

District trainings, targeted site-level supportive supervision, and mentorship on integrated HIV care and treatment services and other related services were implemented in clinical areas over the past five years. Examples include training on ANC, maternity, pediatric, pharmacy, hospital, and laboratory management and administration.

TASK SHIFTINGDespite previous decentralization efforts, only 25% of ANC facilities in Zimbabwe dispensed ART in December 2012. The majority of ANC nurses working at these sites mentioned lack of confidence as a key barrier to ART initiation.22 Following advocacy work at the national level to ensure that nurses were given permission to initiate ART-eligible patients on treatment, EGPAF introduced a clinical mentorship program in 2013. This mentorship took place in seven provinces at 103 sites to increase confidence of Zimbabwean nurses to initiate ART, focusing especially on rural areas where few doctors are available.

In this clinical mentorship program, participating nurses completed a one-week practical training on ART initiation and care of HIV and OIs at ART sites. Many nurses also participated in a clinical attachment at sites specializing in pediatric care and treatment. Following the training and clinical attachment, a multidisciplinary team of mentors (including a doctor, nurse, and pharmacy


OCT-DEC 2012

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Figure 11. Comparison of trends in the uptake of ART initiation in ANC between mentorship sites and control sites

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technician from each district hospital) provided on-site mentorship to these nurses bimonthly for three months. A total of 200 nurses participated; since then, 168 children younger than two years of age were initiated on ART at mentorship sites.

This mentorship program has proved to be an effective method of improving nurses’ confidence to initiate ART and is now part of the national HIV program (see Figure 11).

The fleet management system implemented

by EGPAF-Zimbabwe was another innovation

made possible by CIFF funds. The system was

created in an effort to strengthen EGPAF’s

technical assistance support to the national

PMTCT and pediatric ART program and improve

supply chain logistics. The program supplied 47

vehicles from 2011 to 2013. Between September

2013 and April 2014, EGPAF installed a fleet

management system with telematics, GPS

tracking, and antitheft mechanisms. The system allowed for real-time tracking of vehicles, and it generated reports or alerts on reckless driving. In six months, maintenance costs, speeding alerts, and accidents were reduced and fuel efficiency increased. The system sustains the vehicles for a longer period, allowing required supplies to easily be transported around the country.

INNOVATION: VEHICLE MANAGEMENT SYSTEM

% P

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/ FINAL OUTCOMES AND EVIDENCE OF PERFORMANCE IMPROVEMENT /



Inline with CIFF’s data-driven mission, key performance indicators (KPIs) were monitored throughout the five-year

award. Almost all target indicators were reached each year. However, due to the ambitious targets in years three and four (which were realigned with the national MOHCC PMTCT program targets), several targets were not reached. Despite this, the preliminary results

of the University of California, Berkeley, impact evaluation, released in 2015, indicated near attainment of the elimination goal (less than 5% MTCT rate), and it serves as evidence that the program has continued to perform very well.8 Table 1 depicts the KPI targets and actual achievements by year.

INDICATOR YEAR ONE YEAR TWO YEAR THREE YEAR FOUR YEAR FIVE

Y1 Results

Y1 Target

Y2 Results

Y2 Target

Y3 Results

Y3 Target

Y4 Results

Y4 Target

Y5 Results Jan.–June

Y5 Target

% pregnant women knowing their HIV status in ANC

97% 95% 97% 95% 91% 97% 98% 96% 99% 97%

% HIV-positive pregnant women receiving ARV prophylaxis*

95% 85% 96% 90% N/A N/A N/A N/A N/A N/A

% HIV-positive pregnant women CD4 tested

56% 42% 54% 65% 67% 75% 62% 85% 68% 85%

% eligible pregnant women initiated on ART**

39% 17% 63% 65% 88% 70% 87% 85% 94% 90%

% HIV-exposed infants initiated on ARV prophylaxis

76% 38% 80% 85% 87% 90% 86% 94% 87% 90%

% HIV-exposed infants (< 2 months) tested using DNA polymerase chain reaction

26% 34% 73% 45% 59% 60% 55% 70% 65% 65%

Table 1. Summary of KPI results against annual targets

N/A: not applicable* Zidovudine prophylaxis was being phased out as of Q4 2013 as the country transitioned to Option B+.** The indicator changed to women initiated on lifelong ART as the country started implementing Option B+ in 2014.Source: National Health Information System data


/ SHARING LESSONS LEARNED /



The CIFF-EGPAF partnership resulted in the development of several initiatives focused on strengthening the capacity of all levels of Zimbabwe’s existing health system. The scale-up of health program management and HIV and AIDS

service delivery skills ensured an integrated, sustainable, cost-effective approach to health service delivery improvements. Through this work, CIFF and EGPAF aimed to ensure that the activities implemented and best practices collected were shared with other high-burden settings, building upon the global efforts to eliminate pediatric HIV/AIDS. Some of these lessons were shared through routine technical assistance and through our participation in the IATT mission. Many of these lessons were shared through publications, such as briefs, conference abstracts, technical reports, and journal articles.

To share the valuable outcomes from the CIFF-EGPAF partnership, EGPAF-Zimbabwe joined global conversation around HIV/AIDS through continuous submission to and presentation at national, regional, and international conferences, such as the International AIDS Society (IAS) Conference and the International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA). Starting in 2012, EGPAF-Zimbabwe dramatically scaled up program documentation to international audiences. At IAS 2012, held in Washington, D.C., in addition to the five abstracts submitted on PMTCT and community engagement, EGPAF-Zimbabwe presented a spotlight oral session on innovative POC CD4 technologies. EGPAF-Zimbabwe presented a satellite session at IAS 2012, entitled, “Together We Can: Achieving Virtual Elimination of New Pediatric HIV Infections in Zimbabwe by 2015 through Strategic Public-Private Partnerships.” EGPAF also provided technical assistance in the development of six other abstracts presented by its partners at IAS 2012. In 2013, four abstracts on PMTCT were accepted and presented at two conferences—one was accepted at IAS and three at ICASA. In 2014, 10 more abstracts were accepted and presented at IAS, featuring subjects such as outreach to adolescents, PMTCT demand generation, and ART retention. Finally, in 2015, nine submitted abstracts were presented, featuring work on various improvements to the national M&E and PMTCT health program. The oral presentation accepted at IAS 2015 discussed the use of the critical path to expand and optimize PMTCT programs. Ten abstracts were accepted at ICASA 2015, with one accepted as an oral presentation on the use of Zimbabwe’s patient-tracking system.

In addition, EGPAF-Zimbabwe contributed to several journal articles on WHO guideline implementation, published two program briefs in 2012 highlighting the DFP model and work on the POC CD4 expansion program, and produced annual reports for each year of the award’s activity. The EGPAF-Zimbabwe technical team has recently placed high priority on writing manuscripts to highlight key program results and lessons learned for publication in peer-reviewed journals. One article on the peer facilitator intervention has been submitted for consideration and several other are under development (see Appendix for a list of published documents and manuscripts in progress).


/ CHALLENGES AND FUTURE DIRECTIONS /



Substantial gains have been made in Zimbabwe in the delivery of sustainable, high-quality PMTCT programming under CIFF’s investment. However, several challenges still face EGPAF-Zimbabwe, including the following:

• In the project’s second year, gains in ART access in MNCH settings plateaued and remained stagnant into the third year of the program. To address this consistent challenge, EGPAF increased focus on and use of the critical path, which promoted a better understanding of the gaps and informed several activities to alleviate the problems.

• The proportion of pregnant women booking for ANC early remained low throughout year four. Data from the EDB showed only modest improvements in women booking at or before the 14th week of pregnancy. Although EGPAF and other implementing partners continue to support the MOHCC in this area, it remains a significant challenge because of traditional and cultural beliefs that dictate the stage at which a woman should reveal her pregnancy. Work with communities will be underway through EGPAF’s Advancing Community-Level Action for Improving MCH/PMTCT (ACCLAIM) project, funded by the Bill & Melinda Gates Foundation and administered through the Canadian Department of Foreign Affairs, Trade, and Development (DFATD).

• Despite some improvements in the EID sample transport system and TAT, adequate linkages to early treatment among HIV-infected infants through EID remains an issue. Average TAT of test results for EID remains unfavorably high at 10.1 weeks. In addition, the proportion of children under two months of age who are tested for HIV using DNA PCR is a significant challenge in Zimbabwe; only 55% of children are tested for HIV using DNA PCR, which is 15% lower than the annual target. This low uptake is largely due to

caregivers presenting later than the recommended six weeks of age. Limited integration of EID with other child health platforms, such as immunization clinics and nutrition wards, has contributed to missed opportunities of infants in access to care and treatment. Stronger integration of these early childhood services is an area of needed exploration.

• Retention and adherence rates in the PMTCT program are not strong, though recent improvements have been realized. There is still a need to strengthen adherence counseling and existing community-to-health facility linkages. Health facilities should be assisted to develop standard systems for client tracking and tracing. In addition, a further scale-up of a client-level longitudinal EDB to all health facilities offering HIV and AIDS services could help improve client follow-up and retention in care.

• In the final years of the CIFF-supported program, high rates of POC CD4 machine breakdowns were reported. The maintenance costs were proving to be unsustainable for the program. There is a need to determine a built-in, sustainable maintenance plan for the machines at the time of purchase to cover the machines’ post warranty period. Through EGPAF’s advocacy efforts, the MOHCC engaged Alere, the manufacturers of the PIMA POC CD4 machine, to find a sustainable plan for machine maintenance. In the interim, Alere pledged to repair, at no cost, all machines that were nonfunctional. In the future, maintenance costs will be built into the cost of consumables.

• An ongoing unforeseen challenge has been Zimbabwe’s struggling economy. The MOHCC has been unable to support and absorb all the seconded staff who are essential to fully scale up the supported programs.

Through upcoming new initiatives, EGPAF is set to address some of the aforementioned challenges. With funding from a multicountry grant from UNITAID, EGPAF will be one of the pioneers in rolling out POC EID, which will enable increased identification of HIV-infected infants and linkage to care and treatment, with the aim of addressing the pediatric ART gap. EGPAF also hopes to monitor and sustain the gains made in the PMTCT program by addressing quality-of-service provision, adherence, and retention issues in the context of Option B+.

EGPAF is planning to provide support and technical assistance as Zimbabwe moves forward in the WHO elimination of mother-to-child transmission (EMTCT) pre-validation phase. We will continue resource mobilization efforts in order to assist the Zimbabwean government in addressing ongoing challenges in eliminating pediatric HIV and improving the quality of life of all people living with HIV and AIDS.

CHALLENGES

WHAT’S NEXT?


/ REFERENCES /



1. Joint United Nations Programme on HIV/AIDS (UNAIDS). Together we will end AIDS. http://www.unicef.org/aids/files/aids__togetherwewillendaids_en.pdf. Published 2012. Accessed July 14, 2015.

2. UNAIDS. Gap report 2014. http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdf. Published July 2014. Accessed July 8, 2015.

3. World Health Organization (WHO). Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: recommendations for a public health approach. http://whqlibdoc.who.int/publications/2010/9789241599818_eng.pdf. Published 2010. Accessed July 8, 2015.

4. UNAIDS. Report on the global AIDS epidemic, 2010. http://www.unaids.org/globalreport/documents/20101123_GlobalReport_full_en.pdf. Published November 2010. Accessed July 9, 2015.

5. Kerina D, Babill SP, Muller F. HIV/AIDS: the Zimbabwean situation and trends. Am J Clin Med Res. 2013;1(1):15-22.

6. WHO. Summary country profile for HIV/AIDS treatment scale-up: Zimbabwe, 2005. http://www.who.int/hiv/HIVCP_ZWE.pdf. Published December 2005. Accessed July 9, 2015.

7. Ministry of Health and Child Care (MOHCC), Zimbabwe. Global AIDS response country progress report: Zimbabwe 2014. http://www.unaids.org/sites/default/files/country/documents/ZWE_narrative_report_2014.pdf. Published 2014. Accessed July 9, 2015.

8. University of California, Berkeley. PMTCT effectiveness survey, 2014. Presented at: IAS 2015; Vancouver, Canada.

9. UNAIDS. Global AIDS progress report, 2015. http://www.unaids.org/en/resources/documents/2015/GARPR_2015_guidelines. Accessed July 2015.

10. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. http://apps.who.int/iris/bitstream/10665/85321/1/9789241505727_eng.pdf?ua=1. Published June 2013. Accessed July 2015.

11. Children’s Investment Fund Foundation. About us. https://ciff.org/about-us/. Accessed July 8, 2015.

12. MOHCC. Zimbabwe national HIV and AIDS strategic plan 2011–2015. http://www.nac.org.zw/sites/default/files/Zimbabwe-National-HIV-AIDS-Strategic-2011-2015-Plan.pdf. Published October 2011. Accessed July 2015.

13. Deressa W, Seme A, Asefa A, Teshome G, Enqusellassie F. Utilization of PMTCT services and associated factors among pregnant women attending antenatal clinics in Addis Ababa, Ethiopia. BMC Pregnancy Childbirth. 2014;14:326.

14. McCoy SI, Buzdugan R, Martz TE, Mushavi A, Mahomva A, Padian NS, Cowan FM. Uptake of prevention of mother-to-child HIV transmission (PMTCT) services among women with a recent birth in Zimbabwe. Paper presented at: IAS 2015; Vancouver, Canada.

15. Machakaire AE, Nyamundaya T, Musarandega R, Mahomva A. Using district focal persons (DFPs) to scale up prevention of mother-to-child transmission of HIV (PMTCT) services in Zimbabwe. Poster presented at: AIDS 2014; Melbourne, Australia.

16. Zimbabwe National Statistics Agency (ZIMSTAT) and ICF International. Zimbabwe demographic and health survey 2010–11. Calverton, Maryland: ZIMSTAT and ICF International; March 2012. http://dhsprogram.com/pubs/pdf/FR254/FR254.pdf. Accessed July 2015.

17. UNAIDS. Global plan Zimbabwe fact sheet. http://www.unaids.org/sites/default/files/media/documents/UNAIDS_GlobalplanCountryfactsheet_zimbabwe_en.pdf. Published 2014. Accessed July 14, 2015.

18. Zimbabwe HIV estimates report 2014. Ministry of Health and Child Care. Harare. Tachiwenyika E, Musarandega R, Murandu M, Chideme M, Mhangara M, Chingombe I. Retention and adherence among mothers and infants in the PMTCT program in Zimbabwe: a retrospective cohort study. Poster presented at: AIDS 2014; Melbourne, Australia.

19. UNAIDS. Zimbabwe global AIDS response progress report 2015. http://www.unaids.org/sites/default/files/country/documents/ZWE_narrative_report_2015.pdf. Accessed July 2015.

20. Musarandega R, Mutede B, Muchedzi A, Moga T, Muchuchuti C, Chadambuka A, Ncomanzi T, Nyamundaya T, Maeka K. Exploring the delays in turnaround time for HIV Early infant diagnosis in selected health facilities in Zimbabwe. Paper presented at: IAS 2015; Vancouver, Canada.

21. Musarandega R, Mahomva A, Robinson J, Nyamundaya T, Tumbare E, Dave Sen P, Hakobyan A, Mushavi A. Using the Critical Path for rapid expansion and optimization of a PMTCT program towards elimination of new HIV infections in children. Oral Presentation at: IAS 2015; Vancouver, Canada.

22. The Elizabeth Glaser Pediatric AIDS Foundation. Post-OI/ART training assessment and barriers to initiation report. May 2015.

23. Zimbabwe MOHCC. HIV Estimates for 2013. 2014.


/ APPENDICES /



APPENDIX 1. DOCUMENTATION DEVELOPED WITH CIFF SUPPORT (2011–2015)

ABSTRACTS ACCEPTED AND PRESENTED AT CONFERENCES

INTERNATIONAL AIDS SOCIETY (IAS) 2011, ROME, ITALY Abstract Outcome

Making patient-held cards work: Lessons from the Child Health Card Evaluation in Zimbabwe Poster

Integration of ART in MCH settings: The way forward for increasing access to ART for eligible HIV-positive pregnant women in Zimbabwe

Oral

Experiences in using the Child Health Card in Zimbabwe, towards implementation of 2010 WHO guidelines

Poster

Working with Ministries of Health to strengthen national M&E capacity for HIV/AIDS programs Poster

Community-based health care workers in Zimbabwe—everywhere, for everything and everybody?

E-poster

Family planning usage and counseling needs among HIV-positive women in Zimbabwe Poster

Factors associated with uptake of pediatric HIV testing by mothers accessing HIV treatment and care services

Poster

Factors associated with repeat pregnancy intentions of HIV-positive women attending opportunistic infection (OI)/ART clinic in rural Zimbabwe

Poster

Seeking our own solutions: Community partnerships for community-based comprehensive support centers for orphans and vulnerable children (OVC) aged five years and under in Zimbabwe

E-poster

Strategies to include the private health sector in a comprehensive national PMTCT program in Zimbabwe

E-poster

Facilitating HIV testing, care and treatment for orphans and vulnerable children aged five years and under through community-based early childhood development centers in rural and urban Zimbabwe

E-poster

Loss to follow-up in PMTCT programs—the true picture? Insights from three health centers in Buhera District, Zimbabwe

E-poster

Training in PMTCT: From the classroom to successful implementation E-poster

Repeat pregnancies among women with known HIV-positive status in Chitungwiza, Zimbabwe Poster



AIDS 2012, WASHINGTON, D.C., JULY 22–27, 2012 Abstract Outcome

Mobilizing community engagement in the elimination of new HIV infections in children through capacity building of media practitioners

Poster

Strategies for reducing training costs for the PMTCT program in resource-limited setting Poster

Strengthening district capacity to rapidly scale up PMTCT services using 2010 PMTCT services in Zimbabwe: The district focal person approach

Poster

Provincial PMTCT program situation analysis for Mashonaland East Poster

Evaluating the impact of point-of-care CD4 machines on access to antiretroviral therapy (ART) eligibility screening and ART initiation for HIV-positive pregnant women in Zimbabwe

Oral Poster

Assessing gaps in prevention of mother-to-child transmission of HIV (PMTCT) programming toward the elimination of new HIV infections in children: A rapid assessment of the Zimbabwe national PMTCT program

Poster

A health systems strengthening approach toward elimination of new HIV infections among children and keeping their mothers alive: A Zimbabwe experience

Poster

Collaborating PMTCT campaigns and mobile voluntary counseling and tresting to create demand for PMTCT services and couple HIV counseling and testing: Experiences from urban Zimbabwe

Poster

What can we do to increase facility-based deliveries and subsequent PMTCT program coverage? Reasons for home delivery and preferences for uptake of institutional delivery among mothers who deliver at home in Zimbabwe

Poster

Where do women who deliver at home fall through cracks in the PMTCT continuum of care services? A retrospective study of service uptake among mothers who delivered at home in Zimbabwe

Poster

Improving male participation and uptake of PMTCT services in antenatal care settings: Experiences from Chitungwiza City, Zimbabwe

Poster

IAS 2013, KUALA LUMPUR, MALAYSIA Abstract Outcome

Experiences implementing a peer facilitator program to increase demand for PMTCT services in Hurungwe District, Zimbabwe

Poster

ICASA 2013, CAPE TOWN, SOUTH AFRICA Abstract Outcome

Implementing an electronic patient tracking system for PMTCT in Zimbabwe Poster

Engaging community leaders to generate demand for and uptake of antenatal care and prevention of mother-to-child transmission of HIV services in Hurungwe District, Zimbabwe

Poster

Use of 3G-enabled tablet computers for remote data collection and reporting: Enhancing supportive supervision of maternal and child health facilities offering PMTCT services in Zimbabwe

Oral


SAHARA 2013, DAKAR, SENEGAL Abstract Outcome

Introduction of an electronic database (EDB) for longitudinal follow-up of mother-baby pairs enrolled in PMTCT in Zimbabwe

Poster

Developing a village health worker curriculum to support implementation of the WHO 2010 PMTCT Guidelines in Zimbabwe

Oral

AIDS 2014, MELBOURNE, AUSTRALIA Abstract Outcome

Creating demand for and retention in maternal, neonatal, and child health (MNCH), including prevention of mother-to-child transmission (PMTCT) services: A randomized community-based peer facilitator intervention in rural Zimbabwe

Poster

Strengthening community health facility linkages to generate demand and retention in PMTCT programs: The EGPAF-supported village health worker (VHW) program in Tsholotsho District, Zimbabwe

Poster

Retention and adherence among mothers and infants in the PMTCT program in Zimbabwe: A retrospective cohort study

Poster

Beyond information dissemination: Inspiring journalists to invigorate Zimbabwe’s agenda to eliminate mother-to-child transmission of HIV

Poster

Using district focal persons (DFPs) to scale up prevention of mother-to-child transmission of HIV (PMTCT) services in Zimbabwe

Poster

Using internship opportunities to strengthen the technical skills of undergraduate students to manage HIV/AIDS programs

Poster

Increasing access to PMTCT services among pregnant women in Zimbabwe by using radio to bridge the gap

Poster

Supporting the involvement of adolescents in the prevention of mother-to-child transmission services: The Elizabeth Glaser Pediatric AIDS Foundation-Zimbabwe (EGPAF) program’s mass media communications strategy

Poster

Stepping up evidence-based program management in Zimbabwe using a data-use plan and evidence-based program review meetings

Poster

Piloting an electronic patient tracking system for PMTCT at facilities in Zimbabwe: Reducing health care staff workload

Poster

6th HIV Pediatrics Workshop 2014, Melbourne, Australia Poster

Creating demand for and retention in maternal, neonatal, and child health (MNCH), including prevention of mother-to-child transmission (PMTCT) services: A randomized community-based peer facilitator intervention in rural Zimbabwe

Oral


IAS 2015, VANCOUVER, CANADA Abstract Outcome

Using the critical path for rapid expansion and optimization of a PMTCT program towards elimination of new HIV infections in children

Oral

Exploring the delays in turnaround time for HIV early infant diagnosis in selected health facilities in Zimbabwe

Poster

Using clinical mentorship to increase confidence of Zimbabwean nurses to initiate ART Poster

Improving six months retention of mothers and children on ART: A quality improvement approach

Poster

Are women enrolled in the PMTCT program breastfeeding their infants? Findings from a PMTCT electronic database in Zimbabwe

Poster

Completeness and accuracy of data in Zimbabwe’s national PMTCT program health facility registers: Findings from a patient-level data quality audit

Poster

What factors are critical in improving client satisfaction with PMTCT services in Zimbabwe? Findings from a client satisfaction survey

Poster

Fleet management system: A useful tool in improving efficiency and effectiveness in PMTCT and pediatric ART service support in Elizabeth Glaser Pediatric AIDS Foundation Zimbabwe programs

Poster

Supporting policy-level action for improved health outcomes in Zimbabwe Poster

Facilitating community-led action for optimal uptake of mother-to-child transmission of HIV services in vulnerable communities: The Elizabeth Glaser Pediatric AIDS Foundation—Zimbabwe Community Engagement Program

Poster


ZIMA CONGRESS 2015 HWANGE, ZIMBABWE Abstract Outcome

Can our clients talk back to us? Availability and accessibility of client feedback mechanisms in public health facilities, Zimbabwe, 2014

Oral

Ethical research in vulnerable populations: Acceptability of Option B+ in pregnant and lactating women in Zimbabwe

Oral

Retention of mother-baby pairs in the PMTCT program at their sites of booking in selected sites, April to December 2014: A dataset analysis

Oral

ICASA 2015, ZIMBABWE Abstract Outcome

Do adolescents equally utilize ANC and PMTCT services as adult women? Data from patient tracking database in Zimbabwe

Poster

Barriers to the Accelerated Children’s HIV/AIDS Treatment Initiative in Hurungwe District, Zimbabwe 2015: A qualitative survey

Poster

The Accelerated Children’s HIV/AIDS Treatment Initiative in Hurungwe District, Zimbabwe, 2015: Informing HIV beyond 2015 era through a baseline assessment

Poster

Barriers to PMTCT service uptake and retention within care and treatment in Hurungwe Poster

Engaging the private sector in accelerating progress toward elimination of mother-to-child HIV transmission and in implementation of new World Health Organization (WHO) 2013 HIV guidelines in Zimbabwe

Poster

Using lessons learned from procurement of POC CD4 devices to inform new procurement and supply management of devices for public health delivery system: An EGPAF-Zimbabwe experience

Poster

Stepping up pediatric HIV case identification: Using FedEx to transport early infant diagnostic samples from remote areas in Zimbabwe

Poster

Supporting an integrated specimen transportation system to scale up early infant diagnosis (EID): Sharing experience from Zimbabwe

Poster

Scaling-up WHO-recommended PMTCT services using a health systems strengthening approach in a resource-limited setting: An Elizabeth Glaser Pediatric AIDS Foundation experience in Zimbabwe

Poster

Promoting optimal uptake of antenatal care (ANC) services among women of childbearing-age: Findings of a literature review conducted in Zimbabwe

Poster


2014 MANUSCRIPTS IN PROGRESS Progress to date

Trends in demographic and clinical characteristics of clients accessing PMTCT services—EDB data analysis

In development

Peer-to-peer study: A randomized control trial to evaluate the effectiveness of a community-based peer facilitator intervention in Hurungwe District, 2013

Submitted to journal

Implementing clinical mentorship for PMTCT and pediatric HIV care and treatment in Zimbabwe

In development

DFP model In development

INTERNAL PROGRAM DOCUMENTS

International Family AIDS Initiative, Zimbabwe, 5-Year Country Strategic Plan (2008–2013)

Family AIDS Initiative Program in Zimbabwe, Annual Reports

EGPAF Family AIDS Initiative Program in Zimbabwe, Quarterly Bulletins

Zimbabwe Second National HIV and AIDS Conference Report (2011)

PROGRAM BRIEFS Progress to date

Implementing point-of-care CD4 testing for HIV-positive women and their families in maternal and child health settings: Early lessons (July 2012)

Printed and disseminated

Implementing a district focal person model to strengthen PMTCT service delivery: Early lessons (July 2012)


Helping eliminate HIV and AIDS in children by ensuring access to HIV testing and treatment for pregnant women living with HIV, their children, and partners: Family Policy Brief 1, April 2011


How Zimbabwe is implementing the 2010 World Health Organization (WHO) guidelines and working toward elimination of HIV and AIDS in children: Family Policy Brief 2, April 2011


Technical brief on the electronic patient-level database Being finalized

Technical brief on the clinical mentorship program in Zimbabwe Being finalized


2015 MANUSCRIPTS IN PROGRESS

Retention of HIV pregnant women in PMTCT program in Zimbabwe: A glaring challenge in the face of transition to Option B+

Electronic database in resource-limited settings: Lessons learned

Sites–April to December 2014: A dataset analysis

Community leaders’ engagement for demand generation and retention on MNCH/PMTCT (nested study)

Acceptability of Option B+ among pregnant and breastfeeding women in selected districts in Zimbabwe

Point-of-care CD4 quasi-experimental study analysis of data from of point-of-care CD4 machines (errors rapid assessment) (nested)

What was the level of accuracy and completeness of selected data elements in ANC and postnatal care health facility registers for Zimbabwe’s PMTCT program in 2014? Findings from a patient-level data quality audit

Peer site support as an approach to improve district implementation of PMTCT services: An EGPAF experience 2014 to 2015

Site support supervision: An integral component of program implementation

Client satisfaction component

ACCLAIM knowledge, attitudes, and behavior survey

ACCLAIM formative survey


NATIONAL LEVEL DOCUMENTATION SUPPORT

Document type Document name Year the document was developedStrategic documents Elimination of MTCT

strategy2011, 2014

National POC CD4 machine deployment strategy

2011

Zimbabwe National HIV and AIDS Strategic plan [ZNASP ii] 2011–2015

2011

Quality improvement strategy

2012

Communication strategy 2011, 2015

Option B+ operational plan 2013

Lab policy review and POC policy formulation

2014

Accelerated Children’s HIV/AIDS Treatment Initiative strategy

2015

Zimbabwe HIV viral load scale-up plan: 2015–2018

2015

WHO guidelines National PMTCT /ART guidelines (adaptation of WHO guidelines for PMTCT 2010, 2013)

2010, 2013

Technical surveys and reports

PMTCT national annual reports

2012, 2013, 2014

Review of PMTCT implementation (2006–2010) report

2011

Midterm review of EMTCT strategy implementation (2011–2015) report

2013

Interim review of Option B+ implementation report

2014

Zimbabwe Second National HIV and AIDS Conference report (2011)

2011

The integration of antiretroviral therapy in maternal, neonatal and child health settings In Zimbabwe progress report

2011


Training materials Prevention of mother-to-child transmission (IMAI/IMPAC) facilitators and participant’s manuals

2011

Integrated M&E training manual

2012

Option B+ 2013

Pediatric ART 2011

Clinical mentorship 2013, 2014

HIV integrated training 2013

M&E tools PMTCT registers and report forms

2011, 2013

Postnatal care register 2012

Mother-baby pair register 2015

SOPs ART in MNCH SOPs 2011

Client tracking and tracing SOPs

2013

Job aids PMTCT indicator definition guide

2011, 2014

Child health card (CHC) 2012

CHC manual 2012

Pediatric ART dosing wheel 2013

HIV testing algorithm for children: desk tent

2015

Appointment diary 2013

M&E frequently asked questions and model answers

2012

WHO 2010 guidelines flow charts (ANC and postnatal)

2011

Other tools ART capacity assessment tool

2013

IEC materials Prevention of mother-to-child transmission of HIV in Zimbabwe basic facts pamphlet

2013


REPORTS SUBMITTED TO CIFF

Report Date of submissionProgram reports

Quarterly reports 2011–2015

Annual reports 2011–2014

Research reports

National PMTCT baseline assessment report and 10 district reports January 2012

VHW rapid assessment progress report August 2012

Peer-to-peer OR progress report September 2012

PMTCT retention and adherence survey report November 2013

Post OI/ART management report June 2013

Peer-to-peer OR interim report 2 August 2013

VHW rapid assessment final report November 2013

Patient-level data quality audit and client satisfaction survey report December 2014

Peer-to-peer final report May 2014

Acceptability of Option B+ study report June 2015

APPENDIX 2. MILESTONES SUBMITTED TO CIFF (2011–2015)CIFF MILESTONE TITLE

SUBMISSION MONTH

YEAR 1 (OCTOBER 1, 2010–DECEMBER 31, 2011)1 Revision of WHO PMTCT training module January

2 Prepare procurement package for POC CD4 machines January

3 Issue new subagreements to Family AIDS Initiative partners January

4 Purchase POC CD4 machines and supplies (50) March

5 Select sites for POC CD4 machines March

6 Recruit VHW coordinator March

7 Recruit advocacy and communications officer March

8 Conduct national training of trainers (TOT) in PMTCT package (1) March

9 Recruit DFPs (30) April

10 Develop VHW strategy and plan for follow-up of mother-baby pairs June

11 Health care workers (HCWs) in districts/sites trained in integrated PMTCT package

September

12 HCWs in districts/sites trained in rapid HIV testing September

13 HCWs in districts/sites trained in OI/ART management for MNCH September

14 HCWs in districts/sites trained in EID September


YEAR 1 (OCTOBER 1, 2010–DECEMBER 31, 2011)

15 Develop strategy for community engagement (advocacy and communications officer)

September

16 Pilot/roll-out database in some sites September

17 DFPs conduct supportive supervision September

18 Contract signed with courier December

YEAR 2 (JANUARY 1–DECEMBER 31, 2012)1 Develop DFP strategy (including long-term goal and capacity

development plan)January

2 Revise training guidelines based on results of cost-reduction pilots February

3 Finalize pediatric HIV program proposal February

4 Develop POC CD4 machine deployment plan, including strategies/criteria for site selection, and strategically deploy machines

March

5 Initial review and documentation of clinical mentorship pilot April

6 Install database to remaining 13 main sites April

7 Develop quality assurance framework and build into site support and supervision at district level

June

8 Compile report on VHW intervention July

9 Initiate rapid assessment of POC CD4 intervention September

10 Analyze initial research findings from peer facilitator study September

11 Develop detailed action plan for site support and supervision November

12 Disseminate situational analysis and action plans by DFPs at district level

December

YEAR 3 (JANUARY 1–DECEMBER 31, 2013)1 Identify centers of excellence for clinical attachment February

2 Conduct literature review of local, regional, and international publications on barriers to ANC bookings—to be used to inform communications and advocacy activities aimed at promoting demand for early uptake of PMTCT (consultant)

March

3 Develop data-use plan to build capacity of district facility staff March

4 Expansion of EDB to 4 additional roaming sites (bringing total to 36 sites)

April

5 Development of QI plan to guide implementation of QI activities in Zimbabwe

May

6 Post-OI/ART training assessment and barriers to initiation (DFPs to conduct)

May

7 Develop draft SOPs for patient tracking and tracing (ideally with input later from district community health nurses and sisters in charge for finalization—to come in gap proposal)

June

8 Interim progress report on peer-to-peer OR study June


YEAR 3 (JANUARY 1–DECEMBER 31, 2013)9 Onsite analysis of key adherence and retention indicators to

increase the number of sites in which retention and adherence analysis has been done beyond 36 EDB sites (longitudinal patient-level data, e.g., percentage of pregnant women adherent to zidovudine prophylaxis and ART, percentage of HIV-exposed infants adherent to nevirapine at six weeks). Based on follow-up of client, clinic appointments, and attendances in the site registers.

July

10 Continue VHW assessment in Tsholotsho: Ongoing analysis of program data (including retention indicators) supported by qualitative data collected through focus group discussions

October

11 Identify benchmarks to track district readiness to transition from DFPs

October

12 Track turnaround from dried blood spot sample collection to results received

December

YEAR 4 (JANUARY 1–DECEMBER 31, 2014)1 Support site capacity assessment and readiness for Option B+ February

2 Support clinical attachments / mentorship program April

3 Produce policy briefs for parliamentarians April

4 Support site capacity assessment and readiness for Option B+ June

5 Expand QI initiative July

6 Support sensitization meetings for environmental health technicians on sample transportation

August

7 Facilitate quarterly joint implementation planning, review, and monitoring meetings among PMTCT, OI/ART, and MNCH units

August

8 DFP transition planning (ongoing capacity building of DNOs, discussions with MOHCC / other funders to take over DFP position)

September

9 Support MOHCC to conduct interim Option B+ program review after Phase I and II implementation

October

10 Patient-level data quality audit to determine quality of documentation in patient registers (addressing retention question)

November

11 Support roll-out of the SOP for tracking and tracing December

YEAR 5 (JANUARY 1–DECEMBER 31, 2015)1 Intensive district for pediatric ART scale-up: Develop work plan for

intensive/demonstration district activitiesFebruary

2 Intensive district for pediatric ART scale-up: Develop integrated child health service checklist to facilitate use of all service entry points for identifying HIV-infected children

March

3 Intensive district for pediatric ART scale-up: Focused community dialogue days for pediatric ART

March

4 Maximizing and sustaining gains in PMTCT: Document lessons learned from procurement and roll-out of POC CD4 machines (to inform POC EID and viral load)

April


YEAR 5 (JANUARY 1–DECEMBER 31, 2015)5 Maximizing and sustaining gains in PMTCT:

Finalize OR on acceptability of Option B+ and implement findings

June

6 Transition and sustainability: Engage MOHCC on institutionalization of seconded data entry clerks and national-level staff, as well as sustainability of EID sample transportation and CD4 POC maintenance

June

APPENDIX 3. MEDICAL RESEARCH COUNCIL OF ZIMBABWE APPROVED OPERATIONS RESEARCH

1 Advancing community-level action for improving MCH/PMTCT: Formative and baseline survey

2 Protocol to evaluate the effectiveness of selected community-based interventions to improve maternal and child health and prevention of mother-to-child transmission of HIV outcomes in three countries: Swaziland, Uganda, and Zimbabwe

3 Survey on adherence to ARV pick-up for prophylaxis/ART and retention of mothers and infants in the PMTCT program in Zimbabwe

4 A community randomized study to evaluate the effect of community-based peer facilitator intervention on prevention of mother-to-child transmission (PMTCT) of HIV outcomes in Zimbabwe

5 Analysis of routine program data and documentation and dissemination of lessons learned (nonresearch determination of the EGPAF program)

6 Documentation of lessons learned and analysis and discussion of findings from data collected in the PMTCT program (EDB protocol)

7 Acceptability of lifelong ART / Option B+ at selected sites in Zimbabwe

8 Post OI/ART management training and capacity building assessment in selected districts in Zimbabwe

9 Patient-level data quality audit and client satisfaction survey

10 EID TAT protocol (submitted to MRCZ on November 11, 2014)

11 Assessment accelerating HIV care and treatment (ACT) initiative in Hurungwe District

12 TracTOR–Tracking and Tracing Operations Research: HIV Core Study

This end-of-project report was made possible through financial support provided by the Children’s Investment Fund Foundation (CIFF). We would like to acknowledge the valuable and strong leadership of Zimbabwe’s Ministry of Health and Child Care (MOHCC) and the collaboration of our Family AIDS Initiatives (FAI) implementing partners J.F. Kapnek Charitable Trust, Organization for Public Health Interventions and Development (OPHID), and Zimbabwe AIDS Prevention Project—University of Zimbabwe (ZAPP-UZ). Finally, we would like to acknowledge the support of other donors who contributed to the EGPAF-Zimbabwe program during this time, helping EGPAF to achieve the results discussed in this report through leveraged resources. These donors include DFID, DFATD, and United States Agency for International Development (USAID)/OPHID.

The contents of this report are the sole responsibility of the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF or the Foundation) and do not necessarily reflect the views of MOHCC, CIFF, or our other donors. Unless otherwise stated, it is not implied or to be inferred that any individuals appearing in this publication are living with HIV. All photos unless specified: Elizabeth Glaser Pediatric AIDS Foundation-Zimbabwe.


EGPAF ZIMBABWE

107 King George Road Avondale

Harare, Zimbabwe

P +263 (0)4 302144

WWW.PEDAIDS.ORG

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